Analyzing Chronic Health and Population Data to Identify Priority Populations

In collaboration with the Idaho Department of Health and Welfare, we completed a statewide analysis to better understand how various risk factors contribute to chronic health outcomes in Idaho. The goal of this project was to identify and prioritize populations most at risk, enabling more effective targeting of health interventions and resources.

Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we evaluated potential associations between multiple risk factors and several key chronic health outcomes. Advanced statistical modeling was applied to quantify the strength of these associations through odds ratios. Then, to translate these findings into actionable insights, we incorporated population-level data from the American Community Survey and CDC PLACES county-level estimates. Combined, these data were used to develop composite risk scores for counties across Idaho, and counties were ranked based on their relative risk level.

The resulting risk rankings were developed into a data dashboard and provided IDHW with a data-driven framework for prioritizing high-need communities and aligning resources to support targeted, evidence-based lifestyle interventions. In addition, the analysis revealed that many chronic conditions share common underlying risk factors across the state. This highlighted the importance of integrated, cross-cutting public health strategies rather than condition-specific approaches.

Learn more about our work.

  • Planning Evaluations that Programs Can Use

    Our evaluation approach helps programs gather evidence, generate insights, and make decisions that drive learning, growth, and impact. 

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  • Letting Community Input Drive Health Improvement in Rural Colorado

    In 2024, we conducted a data-driven community health needs assessment to inform the development of this SE Colorado bi-county regions’ 2025–2030 Public Health Improvement Plan.

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  • Conducting a Statewide Cancer Survivors Needs Assessment

    We conducted a comprehensive survivorship needs assessment to identify key gaps in support for cancer survivors, informing recommendations to strengthen resources and care across the state.

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  • Assessing Cancer Survivors' Needs in Wyoming

    Findings from our comprehensive cancer survivor needs assessment are guiding the Wyoming Cancer Coalition’s efforts to address gaps and improve quality of life for cancer survivors statewide.

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  • Using Electronic Health Record Data to Improve Clinical Processes

    We help Idaho health systems use their EHR data for clinical quality improvement that leads to improved cardiovascular care and cancer screening. 

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  • Tailoring Messaging for Increasing Colorectal Cancer Screening

    We worked with ACS NCCRT to create a practical guide that shares real-world examples and strategies for tailoring colorectal cancer screening messaging to improve campaign impact.

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  • Increasing Colorectal Cancer Screening in Rural Communities

    We worked with ACS NCCRT to create a practical guide to improve colorectal cancer screening in rural communities, based on research and interviews with organizations using effective, real-world strategies.

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  • Increasing Access to Counseling in Rural Colorado

    We partnered with the Las-Animas Huerfano Counties District Health Department to design and launch a free telehealth counseling program aligned with community-identified needs, creating a program infrastructure and tools that have supported over 200 free therapy sessions to date.

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  • Wyoming Cancer Plan

    We worked with the Wyoming Cancer Coalition to create their 2026–2030 cancer plan by combining data, stakeholder input, and local context to set measurable, actionable goals that address the burden of cancer in Wyoming.

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  • Using Evaluation as a Tool for Program Improvement in the Rural West

    Since 2022, we have partnered with the Wyoming Cancer Program to design evaluations that go beyond compliance, turning data into actionable insights that improve program operations and reach. By combining program staff expertise with rigorous evaluation methods, our work has guided decision-making, informed resource allocation, and strengthened cancer screening efforts statewide.

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  • Taking a Mixed Methods Approach to Understanding Immunization Access

    Our comprehensive evaluation helped the Wyoming Immunization Unit use their data to improve vaccine access, address barriers, and strengthen program operations.

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  • Data Management and Maintenance

    We protect sensitive health data with HIPAA-compliant systems and strict safeguards, ensuring information is secure and responsibly managed.

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  • Analyzing Chronic Health and Population Data to Identify Priority Populations

    In collaboration with the Idaho Department of Health and Welfare, we analyzed BRFSS and population data to provide a data-driven framework for targeting chronic disease interventions in Idaho.

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  • Supporting Data-Driven Screening and Prevention Services using OSCAR

    Working with CPC Clinical Research and the Las Animas-Huerfano Counties District Health Department we are supporting health screening and prevention efforts in Southeast Colorado using Outreach, Screening and Referral System (OSCAR) software.

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